1. Endocrine investigation of a case of adrenal insufficiency

2. Patient’s particulars   Name XYZ   Age 32 years   Sex Male   Occupation Serving sepoy (SSG)   Address Muzaffarabad - Azad Kashmir   Admitted to MH Rwp 03 Nov 2007

3.   Generalized weakness   Darkened complexion   Anorexia   Weight loss   Dizziness   Frequent loose stools   Vomiting 5 days 2 years Presenting complaints

4. History of presenting complaints   Apr 06 - Seconded to UN mission in Liberia   Jul 06 First presentation: - Weakness, easy fatiguability, vomiting & loss of appetite - Reported to level 2 hospital (Liberia) - Conservatively managed - Reported several times with similar complaints

5. History of presenting complaints (contd)   Jan 07 - Reported again with aggravated complaints - Transferred to level 3 hospital (Liberia) - Worked up for adrenal insufficiency   Mar 07 -Transferred to level 4 hospital (Ghana) for confirmation of the diagnosis - Plasma ACTH assay & MRI abdomen were performed - No medical records available - Advised tab prednisolone for 6 months - Rejoined his unit in Liberia

6. History of presenting complaints (contd)   Apr 07 - Repatriated - Rejoined active service - Continued tab prednisolone   Aug 07 - Compliance declined & discontinued treatment

7. History of presenting complaints (contd)   Nov 07 - Reported to MH Rawalpindi with loose stools & vomiting - Darkened complexion - Weight loss 7 kg - Preference for salty foods   No history of haemetemesis, melaena, jaundice, heat intolerance, palpitations, fever, haemoptysis, polyphagia or polyuria

8.   Past history   Family history   Personal history   Dietary history   Drug history Not contributory History (contd)

9. General physical examination 2000 2007

10.   Pulse 96/min, regular   Blood pressure 100/70mm Hg (supine) 30mm Hg postural drop (systolic)   Temperature 98.4 0 F   Respiratory rate 18/min   Weight 52 kg General physical examination

11. General physical examination (contd)   Pallor   Jaundice   Dehydatrion   JVP Not raised   Thyroid   Fundi Normal   No visual field defects   No evidence of proximal myopathy Absent Not palpable Mild

12. Systemic examination   Central nervous system   Cardiovascular system   Respiratory system   Gastrointestinal system Unremarkable

13. Provisional diagnosis Adrenal insufficiency

14. Blood Counts: Haemoglobin 14.3 g/dL Total leukocyte count 6.0 x 10 /L Neutrophils 55% Lymphocytes 38% Monocytes 3% Eosinophils 4% MCV 82.3 fL Platelets 192 x 10 /L ESR 8 mm fall (end of 1st hr) 9 Investigations 9

15. Investigations (contd)   Plasma glucose fasting & post prandial   Serum urea   Serum creatinine   Serum electrolytes - Na - K - Ca Within reference range Normal + + ++

16. Investigations (contd)   X-ray chest   Sputum for AFB   Mantoux test   TB serology   USG abdomen   X-ray abdomen   Liver function tests Normal No abnormality noted

17. Investigations (contd)   Serum cortisol 9.0 (5-25) µg/dL   Plasma ACTH >1000 (8-79) pg/mL   Serum TSH   Plasma PTH   Serum FSH   Serum LH Within reference range

18.   Basal serum cortisol 8.1 µg/dL (5-25 µg/dL)   Inj synacthen (synthetic ACTH) 250µg administered I/M   Serum cortisol after 30 mins 8.77 µg/dL   Serum cortisol after 60 mins 9.19 µg/dL Short synacthen test

19. Investigations (contd)   Autoimmune profile: Anti adrenal antibodies Thyroid microsomal antibodies Negative Antinuclear antibodies   Contrast enhanced MRI abdomen Small sized adrenal glands with no calcification   HIV serology Negative

20. Final diagnosis Idiopathic adrenal insufficiency

21.   Inj ciprofloxacin 500mg I/V twice daily Replacement therapy:   Tab prednisolone 10mg (morning) and 5mg (evening)   Tab fludrocortisone 0.05mg once daily Management

22. Follow up   Appetite has improved   Gained 4 kg of weight   No postural variation in blood pressure